Manager - Hospital & Medical Integrity

2 weeks ago

Melbourne, Australia Bupa Dental Care Full time

**Posted** 06/11/2023

**Job Number** 23479

**Full/Part** Full Time

**Posting End Date** 22/12/2023

As the Manager - Hospital & Medical Integrity the key focus of this role is to prevent leakage through the reduction of fraud, waste, abuse and error of hospital and medical claims. You will be responsible for managing the identification, mitigation, elimination and management of claim inaccuracy and leakage.

The role demands a strong leader in the field of Private Health Insurance or from a Hospital Setting who has demonstrated the ability to take complex issues, resolve them in an innovative way and deliver on strong quantitative outcomes.

**How will I help?**
- Manage a team of auditors across hospital and medical utilisation, DRG audits and desktop audits within an agreed annual work program
- Lead the management of provider onsite audits, manage end to end processes including follow up and financial management of incorrect billing - approximately 10 audits per year.
- Work closely with prosthesis integrity, hospital and medical contracting teams to ensure we maximise leverage of contracting terms and identify new areas of actual and potential claims leakage.
- Manage the process to review individual hospital and medical claims to advise where there are incorrect, inappropriate or servicing practices, and instigate recoveries
- Negotiate financial recoveries from hospital and medical providers and keep aged debt (>12 months) to a minimum.
- In conjunction with the Head of Claims Integrity, develop claims leakage strategies aligned with our focus areas (including prevention) to support the meeting of financial targets. These will include areas such as systematising case management and automation of workflow.
- Monitor utilisation trends across the industry, providing insight to relevant stakeholders through participation in industry group forums.
- Maintain a high performance hospital and medical integrity team which achieves KPI targets whilst ensuring the Team maintains good relationships with external stakeholders (Providers) as well as internal stakeholders.

**What’s in it for me?
When you work at Bupa, we support your career and your lifestyle. We want to reward and celebrate our people. With a healthy work/life balance, leadership support, reduced private health cover, study leave and a commitment to promoting from within. Health and wellbeing is our top priority and it’s at the heart of everything we do. And we’ll make sure you feel it every day.

**What do I need?**
- Degree qualified in Finance, Commerce or an area of Healthcare (eg. Nursing, Physiotherapy, Healthcare Informatics etc). Clinical experience highly regarded.
- Mid-level management experience leading a large team, operating either in health insurance or healthcare.
- High level knowledge of private and public health.
- Worked within a large, complex environment with multiple legacy systems.
- Ability to work collaboratively and effectively influence a diverse range of stakeholders.
- Experience building and developing a high performing team of diverse skill sets.

**What is it like to work there?
Bupa is an international healthcare group which has been committed to a purpose of helping people live longer, healthier, happier lives and making a better world for more than 70 years.

Bupa Asia Pacific operates in Australia, New Zealand, and Hong Kong, supporting about 6.5 million customers through a broad range of health and care services including health insurance, aged care, dental, medical, optical, and hearing services.

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